12/2/09

Under the withering barrage of recent guideline changes, doctors and patients alike have raised their hands in surrender. It seems like guideline group after group have changed their recommendations to say (more or less) the same thing: "[name of screening test here] should be discussed with the patient according to their risk profile."

We used to think that population studies ("big-E epidemiology") would provide us with the tools to fix health care. The drill of empirical science would become the Swiss Army knife of evidence-based medicine.

But something got in the way: inconveniently enough, that something is the patient.

A patient is not a population, but a unique individual with a one-of-a-kind combination of characteristics. So how to apply the population findings (or even the evidence-based recommendations) to the individual? As Karla Kerlikowske says in the latest issue of the Annals of Internal Medicine ("Evidence-Based Breast Cancer Prevention: The Importance of Individual RIsk"): "We urgently need risk models with better discriminatory accuracy . . . that can accurately identify individuals at all levels of risk."

So that's one way of bridging the gap. But there's another way which is just as central: making sure the patient is informed enough (about their own desires, even - about their own priorities) to make them a partner in decision-making. Because how can evidence-based medicine leap the gap from the journal to the bedside without the patient taking hold of it themselves?